CN113423459A

CN113423459A - Cardiac treatment system using external and internal leads

Info

Publication number: CN113423459A
Application number: CN202080014049.6A
Authority: CN
Inventors: Z·C·杨
Original assignee: Medtronic Inc
Current assignee: Medtronic Inc
Priority date: 2019-02-14
Filing date: 2020-02-04
Publication date: 2021-09-21
Also published as: WO2020167517A1; EP3924034A1; US20200261734A1; JP2022520314A

Abstract

A lead system may include a first implantable lead having a first electrode and a second implantable lead having a second electrode, the second implantable lead being guided to an implantation site by the first implantable lead. The second electrode may be implanted in the patient's heart at the same implant site or a second implant site remote from the first electrode. The lead system may be delivered to one or more implant sites using various methods, including at the koch triangle for treatment from the atrium to the ventricle (VfA), at the right ventricular septum wall for bibundle branch pacing, or in the coronary vasculature for left side sensing and pacing.

Description

Cardiac treatment system using external and internal leads

Technical Field

The present technology relates generally to implantable medical devices, systems, and methods. In particular, the present technology relates to implantable lead delivery for cardiac sensing and therapy.

Background

An Implantable Medical Device (IMD), such as a cardiac pacemaker or implantable cardioverter defibrillator, delivers therapeutic stimulation to a patient's heart. Patients with abnormal conduction systems, such as poor conduction in the Atrioventricular (AV) node or poor functioning of the Sinoatrial (SA) node, may receive IMDs such as pacemakers to restore a more normal heart rhythm and AV synchrony. Some types of IMDs, such as cardiac pacemakers, implantable cardioverter-defibrillators (ICDs), or Cardiac Resynchronization Therapy (CRT) devices, provide therapeutic electrical stimulation to a patient's heart through electrodes on one or more implantable endocardial, epicardial, or coronary venous leads positioned in or adjacent to the heart. Therapeutic electrical stimulation may be delivered to the heart in the form of pulses or shocks for pacing, cardioversion, or defibrillation. In some cases, the IMD may sense intrinsic depolarization of the heart and control delivery of therapeutic stimulation to the heart based on the sensing.

Existing pacing techniques involve pacing one or more of the four chambers of the patient's heart 12: the Left Atrium (LA)33, the Right Atrium (RA)26, the Left Ventricle (LV)32, and the Right Ventricle (RV)28, all of which are shown in the front view of the frontal portion of the patient's heart 12 shown in FIG. 1. Some therapeutic pacing techniques involve the cardiac conduction system. The cardiac conduction system (like "highway") can be described as rapidly conducting electrical impulses, while the paced myocardial tissue can slowly conduct electrical impulses like "traveling on mud". The cardiac conduction system includes SA node 1, atrial internode bundles 2, 4, 5 (i.e., anterior internode 2, medial internode 4, and posterior internode 5), atrioventricular node (AV node) 3, hess bundle 13 (also known as the atrioventricular bundle or hess bundle), and bundle branches including Left Bundle Branch (LBB)8a and Right Bundle Branch (RBB)8 b. Fig. 1 also shows the aortic arch 6 and the barkman bundle 7. The SA node located at the junction of the superior vena cava and the right atrium is considered a natural pacemaker of the heart because it continuously and repeatedly emits electrical pulses. The electrical impulse travels through the muscle of RA 26 to LA 33 to cause synchronous contraction of the atria. The electrical impulse is also delivered to the AV node 3 through the atrial nodal tract, the only connection between the atrium and ventricle.

Conduction through the AV node tissue takes longer than through the atrial tissue, resulting in a delay between atrial contraction and the onset of ventricular contraction. The AV delay is the delay between atrial and ventricular contractions, which allows the atrium to empty blood into the ventricles. The valve between the atrium and ventricle then closes before causing the ventricle to contract through the branches of the hessian bundle.

The bundle of his 13 is located in the atrioventricular septum near the tricuspid annulus. The bundle of hessly 13 is divided into a right bundle branch 8a and a left bundle branch 8b, and is formed of a dedicated fiber called "Purkinje fibers" 9. The purkinje fibers 9 can be described as rapidly conducting action potentials along the ventricular septum, rapidly expanding depolarization wavefronts through the remaining ventricular myocardium, and producing coordinated contraction of the ventricular muscle groups.

Disclosure of Invention

The technology of the present disclosure relates generally to lead-in systems and methods for cardiac therapy. The lead system is introduced to allow the leads to be translatable or rotatable relative to each other to facilitate capturing a desired portion of the patient's heart. In other words, the lead-in system may provide a customized implant plan for each patient.

In one aspect, the present disclosure provides a method that includes implanting a first implantable lead to implant a first electrode of the first implantable lead at a first implantation site in a coronary sinus or a coronary vein of a heart of a patient. The method also includes advancing a second implantable lead having a second electrode guided by the distal portion of the first implantable lead to a second implantation site in a coronary vein of the patient's heart distal to the first electrode. The method further includes implanting a second electrode at a second implantation site.

In another aspect, the present disclosure provides a method that includes advancing a second implantable lead having a second electrode to a location in a coronary sinus or a coronary vein of a heart of a patient, the second implantable lead being guided by a distal portion of a first implantable lead having a first electrode. The method further includes implanting a first electrode at a first implantation site in a coronary sinus or a coronary vein of a heart of the patient, and penetrating a pericardial space of the heart of the patient through a vessel wall at a location in the coronary sinus or the coronary vein. The method further includes advancing a second implantable lead into the pericardial space through the puncture in the vessel wall, and implanting a second electrode from the pericardial space into the myocardium of the patient's heart at a second implantation site remote from the first implantation site.

In another aspect, the present disclosure provides a method that includes implanting a first implantable lead to implant a first electrode of the first implantable lead at a first implantation site in a coronary sinus or a coronary vein of a heart of a patient. The method also includes advancing a second implantable lead having a second electrode guided by the distal portion of the first implantable lead to a second implantation site in a Left Ventricular (LV) myocardium of the patient's heart distal to the first electrode. The method further includes implanting a second electrode at a second implantation site.

In another aspect, the present disclosure provides a system that includes a first implantable lead having a distal portion and a first electrode coupled to the distal portion of the first implantable lead. The first electrode is configured to be implanted at a first implantation site in a coronary sinus or a coronary vein of a heart of a patient. The system also includes a second implantable lead having a distal portion and a second electrode coupled to the distal portion of the second implantable lead. The second electrode is configured to be implanted at a second implantation site in the patient's heart distal from the first electrode. The distal portion of the second implantable lead is guided to the first implantation site by the distal portion of the first implantable lead.

The details of one or more aspects of the disclosure are set forth in the accompanying drawings and the description below. Other features, objects, and advantages of the technology described in the disclosure will be apparent from the description and drawings, and from the claims.

Drawings

Fig. 1 is an illustration of a patient's heart as one example of an environment for using the lead introduction systems and methods of the present disclosure.

Fig. 2-3 are schematic diagrams of examples of lead in systems according to the present disclosure for use with, for example, the patient's heart of fig. 1.

Fig. 4-5 are distal and proximal schematic views, respectively, of the lead in system of fig. 2.

Fig. 6-7 are schematic diagrams of electrical connectors according to the present disclosure that may be used with, for example, the lead-in lead system of fig. 2-3 to couple a lead to an IMD.

Fig. 8 is a flow chart of one example of a method for delivering the lead in system of fig. 2-3.

Fig. 9-11 are schematic illustrations of various stages of delivery of a lead wire system for cardiac therapy from an atrium to a ventricle according to the present disclosure for use with, for example, the lead wire system of fig. 2-3.

Fig. 12 is a flow chart of one example of a particular method for delivering a lead in system for cardiac therapy from an atrium to a ventricle for use with, for example, the lead in system of fig. 2-3 in accordance with the present disclosure.

Fig. 13 is a schematic illustration of an environment for a lead in system, such as one of the lead in systems of fig. 2-3, for cardiac therapy from an atrium to a ventricle using defibrillator leads according to the present disclosure.

Fig. 14-16 are schematic illustrations of various stages of delivery of a lead in system for dual bundle branch cardiac therapy according to the present disclosure for use with, for example, the lead in system of fig. 2-3.

Fig. 17 is a flow chart of one example of a particular method for delivering a lead in system for dual bundle branch cardiac therapy according to the present disclosure for use with a lead in system such as that of fig. 2-3.

Fig. 18 is a schematic view of one example of a lead wire system (such as one of the lead wire systems of fig. 2-3) for dual bundle branch cardiac therapy for use with atrial leads according to the present disclosure.

Fig. 19 is a schematic diagram of one example of a lead-in lead system (such as one of the lead-in lead systems of fig. 2-3) for dual beam cardiac therapy for use with atrial leads and defibrillator leads according to the present disclosure.

Fig. 20-22 are schematic diagrams of examples of lead in systems for left-side cardiac therapy in coronary vasculature, such as the lead in systems of fig. 2-3, according to the present disclosure.

Fig. 23 is a schematic view of one example of an implantable medical device for use with a lead in system such as that of fig. 2 or 3.

Detailed Description

The present disclosure relates to lead-in systems and methods for cardiac therapy. The lead-in approach may provide efficient and effective delivery of electrodes to various locations in a patient's heart, including at the koch triangle for atrial-to-ventricular (VfA) therapy, at the right ventricular septum wall for bibundle branch pacing, and in the coronary vasculature for left side sensing and pacing. VfA treatment may involve providing electrodes to capture the LV implanted through the AV septum (such as the RA to LV septal wall). The lead system includes a first implantable lead and a second implantable lead. One of the leads may be a bipolar lead and the other lead may be a monopolar lead. The leads may include passive electrodes to monitor electrical activity or active electrodes to provide pacing pulses. The lead system is introduced to allow the leads to be translatable or rotatable relative to each other to facilitate capturing a desired portion of the patient's heart. In other words, the lead-in system may provide a customized implant plan for each patient.

As used in this specification and the appended claims, the term "or" is generally employed in its sense including "and/or" unless the context clearly dictates otherwise.

Reference will now be made to the accompanying drawings that depict one or more aspects described in this disclosure. However, it should be understood that other aspects not depicted in the drawings are within the scope of the present disclosure. Like reference numerals are used to refer to like components, steps, etc. It should be understood, however, that the use of a reference character to refer to an element in a given figure is not intended to limit the element in another figure labeled with the same reference character. Furthermore, the use of different drawing characters to refer to elements in different drawings is not intended to indicate that the different referenced elements may not be the same or similar.

Various embodiments of the present disclosure provide lead in systems for cardiac or other therapies. Fig. 2 and 3 show different examples of lead-in wire systems. Fig. 2 shows a system 100 that includes a first implantable lead 102 and a second implantable lead 104 that operably couple an IMD 16, and further includes a stylet 130. Fig. 3 shows a system 150 that further includes the first implantable lead 102, the second implantable lead 104, the IMD 16, and the guidewire 106 in place of the stylet 130. The system 100 and the system 150 may be similar in many respects, except as described herein.

IMD 16 may be any suitable device known to one of ordinary skill in the art having the benefit of this disclosure that is capable of being operably coupled to one or more implantable leads and one or more electrodes to sense electrical activity or deliver therapy. IMD 16 may be, for example, an implantable pacemaker, cardioverter, and/or defibrillator that provides electrical signals to the patient's heart via electrodes coupled to one or more of the leads. Other non-limiting examples of IMD 16 include: pacemakers with medical leads, ICDs, intracardiac devices, subcutaneous ICDs (S-ICDs), and subcutaneous medical devices (e.g., neurostimulators, inserted monitoring devices, etc.). An example of IMD 16 is shown in fig. 23.

Various implant sites can be targeted using a lead-in system. In one or more embodiments described herein, the system is configured to be implanted in a koch triangle region in an atrial wall of a patient's heart in a tissue structure between a right atrium and a left ventricle of the patient's heart. In one or more embodiments described herein, the system is configured to be implanted in a ventricular septum wall in a tissue structure between a right ventricle and a left ventricle of a heart of a patient. In some embodiments described herein, the system is configured to be implanted in the coronary sinus or coronary vein. Further, in some embodiments described herein, the system is configured to be implanted in the LV myocardium.

As shown in fig. 2 or fig. 3, the first implantable lead 102 can be mechanically coupled to the second implantable lead 104 by a lead fixation element 103. In some embodiments, the first implantable lead 102 and the second implantable lead 104 may be formed separately. In such a configuration, the leads may be advanced one at a time. The second implantable lead 104 can be advanced to the implantation site through the lumen of the first implantable lead 102, for example, after the first implantable lead has been secured at the implantation site. In other embodiments, the first implantable lead 102 and the second implantable lead 104 may be formed as a single lead assembly or assembled leads configured to be advanced toward the implant site simultaneously.

The lead fixation element 103 may be described as a plug coupled between the leads. The lead fixation elements 103 may facilitate translation or rotation of the leads relative to each other. In one or more embodiments described herein, the first implantable lead 102 may be translated relative to the second implantable lead 104 along a longitudinal direction, which may facilitate proper positioning of the leads during implantation to sense electrical activity or deliver cardiac therapy. The second implantable lead 104 may be translated to extend or advance distally from one end of the first implantable lead 102 to penetrate further into tissue structures or to extend further distally into space than the first implantable lead.

As used herein, a "longitudinal" direction refers to a direction along or parallel to a direction between a proximal portion and a distal portion of an elongate member (such as an implantable lead).

The system 100 can define a proximal portion 110 and a distal portion 112, as well as a proximal end and a distal end. As shown, the hyperbola between the proximal portion 110 and the distal portion 112 indicates that the lead may be longer than shown. Each of the first and second implantable leads 102, 104 can further include respective proximal and distal portions, as well as respective proximal and distal ends.

The second implantable lead 104 may be at least partially housed within the first implantable lead 102, e.g., to guide the second implantable lead. In some embodiments, the first implantable lead 102 can include a lumen 105 sized to receive the second implantable lead 104. In some embodiments, the opening of the lumen 105 may be larger than the cross-section of the second implantable lead 104. A sealing element 107 can be coupled between the implantable leads to seal a distal portion of the first implantable lead 102 from fluid ingress, e.g., at or near the distal end. In other words, the sealing element 107 may prevent or substantially prevent fluid from entering the interior of the lumen 105 to the space between the implantable leads.

A guidewire or stylet may be used to advance and guide the lead introduction system 100 to one or more implantation sites. A guidewire or stylet may be at least partially received into the lumen of the second implantable lead 104. As shown in fig. 2, the stylet 130 can be at least partially received within the lumen of the second implantable lead 104 from the proximal end of the lead. The distal end of the stylet 130 can be retained within a distal portion of the second implantable lead 104, e.g., near the closed distal end of the second implantable lead. As shown in fig. 3, a guidewire 106 can be at least partially received within the lumen of the second implantable lead 104 from a proximal end of the lead and can extend distally from the lead. In one or more embodiments described herein, the guidewire 106 can be used to penetrate or pierce tissue structures of a patient's heart.

In other embodiments, the second implantable lead 104 may not include a lumen. For example, the guidewire 106 may extend through the lumen 105 of the first implantable lead 102, and the guidewire 106 may be interchanged with the second implantable lead 104 during the implantation procedure.

As used herein, "tissue structure" refers to any structure that forms the heart, such as the tissue of the heart wall. The tissue structure may define a surface of the heart. Non-limiting examples of tissue structures include an atrioventricular septal wall (e.g., the RA-LV septum), a ventricular septal wall (e.g., the RV-LA septum), a wall forming the apex of a patient's heart, and a vessel wall (e.g., the vessel wall of a coronary sinus or coronary vein).

The first implantable lead 102 may be used to guide the second implantable lead 104 to an implantation site or past a first implantation site to a second implantation site. In one or more embodiments described herein, the distal portion of the first implantable lead 102 can be used to guide the distal portion of the second implantable lead 104 to, for example, the same implantation site. For example, in one or more embodiments described herein, the implant site may be ventricular septal wall in a koch triangle region or basal (e.g., high basal or high septal) region or an intercordous (e.g., low septal or near apical) region in the atrioventricular septal wall of the patient's heart. The Koch triangle of Koch region implanted in the atrial septal wall may facilitate pacing of the hessian beam or the ventricular myocardium. Implantation of the basal region of the ventricular septum wall may facilitate hessian bundle-supported pacing. Implantation in the region between the hearts may facilitate pacing of purkinje fibers.

In other embodiments, the distal portion of the first implantable lead 102 can be implanted at a first implantation site, and the distal portion of the second implantable lead 104 can be implanted distally at a second implantation site. For example, in one or more embodiments described herein, the first implant site may be in a coronary sinus or coronary vein of the patient's heart and the second implant site may be distal to the first implant site in the coronary vein or myocardium (e.g., left ventricular myocardium) of the patient's heart. In one or more embodiments described herein, the second implantation site may be in the myocardium outside of the coronary sinus and coronary veins through an epicardium of the patient's heart. In other words, the pericardial space may be used to access a second implantation site in the myocardium.

The implant leads may be secured or fixed for simultaneous or separate implantation. For example, the first implant lead 102 may be secured before, during, or after the second implant lead 104 is secured. In some embodiments, one of the implant leads may be secured after the other of the implant leads is secured for implantation. In one example, the second implant lead 104 may be secured for implantation after the first implant lead 102 is secured for implantation. In another example, the first implant lead 102 may be secured for implantation after the second implant lead 104 is secured for implantation.

The second implantable lead 104 may be free to rotate relative to the first implantable lead 102, or vice versa, which may facilitate certain types of fixation for implantation. For example, rotational motion can be used to secure the first implantable lead 102 or the second implantable lead 104 to an implant site using a fixation element that is responsive to the rotational motion.

In one or more embodiments described herein, one or both implant leads may include a fixation element for securing the respective lead to tissue structures at a selected implant site. Non-limiting examples of fixation elements include drills and screws. In one or more embodiments, as shown in fig. 2, the system 100 includes a fixation element 108 of the first implantable lead 102, the fixation element 108 can include a helical structure, and a fixation element 109 of the second implantable lead 104 can include a drill structure. In one or more embodiments, as shown in fig. 3, the system 150 includes the fixation element 108 of the first implantable lead 102, the fixation element 108 can include a helical structure, and the fixation element 111 of the second implantable lead 104 can include a helical structure.

In general, any suitable type of drill or helical structure known to those of ordinary skill in the art having the benefit of this disclosure may be used for the fixation element. The fixation elements of the implantable lead may be configured to rotate in the same or opposite directions. For example, one fixation element may be configured to screw into the tissue structure when the respective lead is rotated clockwise, while another fixation element may be configured to screw into the tissue structure when the respective other lead is rotated clockwise (e.g., the same direction) or counterclockwise (e.g., opposite direction). In addition to, or in lieu of, the fixation element, one or both implant leads may include a beveled lead structure to facilitate fixation of the respective implant lead in a blood vessel, such as the coronary sinus or coronary vein.

In one or more embodiments described herein, the piercing element 114 can extend distally from the guidewire 106. The piercing element 114 may be integrally or separately formed with the guidewire 106. Piercing element 114 may have a drilling configuration that may be used to drill into tissue structures at the implantation site. In one or more embodiments described herein, when a penetrating element 114 is used, the fixation element 111 of the second implantable lead 104 can have a helical configuration as shown in fig. 3. In one or more embodiments described herein, the fixation element 109 of the second implantable lead 104 can have a drill configuration as shown in fig. 2 when the guidewire 106 is not used. In one or more other embodiments described herein, the guidewire 106 with a piercing element 114 can be used with a fixation element 109 with a drill structure. For example, the guidewire 106 may extend through the lumen of the fixation element 109 and extend distally from the fixation element 109. In other words, the guidewire 106 may be used with the system 100 of fig. 2 in place of the stylet 130.

The piercing elements 114 may be used to provide micro-piercing holes through tissue structures (e.g., blood vessel walls) of a patient's heart. For example, a micro-puncture into the pericardial space of a patient's heart may be made at a location along the coronary sinus or coronary vein. In other words, a micro-puncture may be formed below the coronal oblique diaphragm plane of the patient's heart. In some embodiments, the piercing element 114 comprises a microneedle configured to provide a micro-puncture in the coronary sinus or coronary vein.

As used herein, the term "micro-puncture" refers to a puncture through a wall that has a maximum dimension, e.g., along a major axis or diameter, of less than about 1 millimeter, or about 100 microns, about 10 microns, or about 1 micron.

When a puncture is formed in a vessel wall, the structure of first implantable lead 102 can be configured to seal the puncture after implantation. In some embodiments, the structure may include a lead body or sheath of an implantable lead. For example, the first implantable lead 102 may be secured against a vessel wall toward the pericardial space. The vessel wall may be sealed by active fixation and the second implantable lead 104 may extend radially from the first implantable lead 102, through the vessel wall and into the pericardial space. In some embodiments, the structure may include a sealing element 107.

As used herein, the phrase "sealing the puncture" refers to a partial seal, a complete seal, or an almost complete seal of the puncture between the blood vessel and the patient's heart space. For example, the seal of the puncture may be sufficient to prevent large tamponades (e.g., caused by fluid accumulation in the pericardial space).

One or both of the implantable leads include one or more electrodes. In some embodiments described herein, the first implantable lead 102 includes a first electrode 122 coupled to the first implantable lead, and the second implantable lead 104 includes a second electrode 124 coupled to the second implantable lead. Each fixation element may be formed integrally with or separately from the respective electrode. In the illustrative embodiment shown in fig. 2 and 3, the electrodes are integrally formed with their respective fixation elements. The integrally formed electrodes are configured to penetrate into tissue structures of a heart of a patient. In one or more embodiments described herein, integrally formed electrodes are formed at the distal portion or end of the respective fixation elements.

First electrode 122 or second electrode 124 can be disposed at a distal portion or end of a respective implantable lead. In one or more embodiments described herein, first electrode 122 or second electrode 124 can be disposed proximate a distal end of a respective implantable lead, e.g., when the structure of the respective implantable lead is used to seal a puncture in a tissue structure (e.g., a vessel wall).

The first electrode 122 and the second electrode 124 may be described as cathode electrodes (or simply cathodes) for pacing or sensing. For example, the electrodes may provide various pacing vectors for different cardiac therapies, such as CRT. Either the first implantable lead 102 or the second implantable lead 104 may include a return electrode 126, which may be described as a common anode electrode (or simply anode). In the embodiment shown in fig. 2 and 3, the return electrode 126 is coupled to the first implantable lead 102 and is shown as a ring electrode. The return electrode 126 may be closer to or farther from the cathode electrode. The return electrode 126 may be proximate the first electrode 122 and proximate the second electrode 124. An implantable lead having two electrodes (e.g., a cathode electrode and an anode electrode) can be described as a bipolar lead.

In one or more embodiments described herein, the second implantable lead 104 includes a plurality of second electrodes 124 (e.g., a plurality of second electrodes) that may be used to provide a plurality of sensing or pacing sites along the lead. The first electrode 122 and the return electrode 126 may be proximate to one or more of the plurality of second electrodes 124.

In one or more embodiments described herein, the first electrode 122 is configured to be implanted at an implantation site on or in a tissue structure of the patient's heart, and the second electrode 124 is configured to be implanted at the same implantation site within the tissue structure of the patient's heart that is distal from the first electrode. After one electrode is implanted, the other electrode may be translated relative to the implanted electrode. For example, even after the first electrode is implanted, the second electrode 124 may be translated relative to the first electrode 122 to allow implantation of the second electrode at various depths within tissue structures of the patient's heart. The translatable coupling of the first implant lead 102 and the second implant lead 104 may facilitate a translatable relationship between the electrodes.

In one or more embodiments described herein, the first electrode 122 is configured to be implanted at a first implantation site in a coronary sinus or a coronary vein of a patient's heart, and the second electrode 124 is configured to be implanted at a second implantation site in the patient's heart distal from the first electrode. For example, the second electrode 124 may be implanted in a coronary vein.

One or more electrodes may be configured to sense electrical activity or provide pacing pulses (e.g., in delivering cardiac therapy). In one or more embodiments described herein, both first electrode 122 and second electrode 124 are configured to provide pacing pulses. One or both electrodes may also be configured to sense electrical activity. In one or more embodiments described herein, the first electrode 122 is configured to sense only electrical activity, and the second electrode 124 is configured to provide pacing pulses. The second electrode 124 may also be configured to sense electrical activity. In some embodiments, the plurality of second electrodes 124 may be configured to deliver cardiac therapy to the left ventricle or sense electrical activity of the left ventricle.

In general, one or more electrodes may be configured to deliver electrical pulses to test one or more locations of the respective electrodes in the patient's heart. In one or more embodiments described herein, one or more depths of the respective electrodes in the tissue structure of the patient's heart may be tested. The test electrical pulse may facilitate identifying an appropriate depth or an appropriate surface location on the tissue structure so that the electrode captures the desired sensing or pacing. In one or more embodiments described herein, the first electrode 122 or the second electrode 124 may be tested at a variable depth or surface location before the first electrode 122 or the second electrode 124 is implanted at the selected depth. In one example, the implant depth or surface position of the first electrode 122 may be tested to determine whether to capture an RBB, and the implant depth of the second electrode 124 may be tested to determine whether to capture an LBB. In another example, the surface location of the first electrode 122 may be tested to determine whether RA myocardium was captured, and the implantation depth of the second electrode 124 may be tested to determine whether LV myocardium or hessian beam was captured.

In one or more embodiments described herein, one or more locations of respective electrodes in a heart of a patient may be tested. In one example, first electrode 122 may be tested to determine if LA is captured and second electrode 124 may be tested to determine if LV is captured. The electrodes may be advanced through a blood vessel of the patient's heart, such as the coronary sinus or coronary vein. For example, the first electrode 122 may be tested at one or more locations in and along the blood vessel to capture LA. Additionally or alternatively, one or more locations of the second electrode 124 in the blood vessel or in the myocardium along the blood vessel may be tested, for example to capture the LV. In addition, one or more of the electrodes may be advanced into a space of the patient's heart, such as the pericardial space. One or more locations of the second electrode 124 along the pericardial space in the myocardium may be tested, for example, to capture the LV.

Although both electrodes may be implanted at the same implantation site, different portions of the patient's heart may be captured by advancing the electrodes to different depths. In one or more embodiments described herein, the first electrode 122 may be implanted in the RA of the patient's heart to deliver cardiac therapy to or sense electrical activity of the RA of the patient's heart, and the second electrode 124 may be implanted from the koch triangle region of the RA of the patient's heart to deliver cardiac therapy to or sense electrical activity of the LV in a basal region, a spacer region, or a basal septum region of the left ventricular myocardium of the patient's heart for VfA cardiac therapy.

In one or more embodiments described herein, the first electrode 122 may be implanted closer to a first bundle branch of the cardiac conduction system of the patient's heart than the second electrode 124, and the second electrode may be implanted closer to a second bundle branch of the cardiac conduction system of the patient's heart than the first electrode. For example, the first electrode 122 may be implanted closer to the RBB 8b (fig. 1), and the second electrode 124 may be implanted closer to the LBB 8a (fig. 1). An implantable lead may be implanted into ventricular septum wall from RV toward LV, which may facilitate placement of first electrode 122 near RBB 8b and second electrode 124 near LBB 8 a. The electrodes may be used to deliver a dual bundle cardiac therapy to RBB 8b and LBB 8a (e.g., using pacing pulses) or to sense electrical activity of RBB 8b and LBB 8a (e.g., electrical sensing).

One or both implantable leads may include a sheath or lead body and one or more conductors extending within the sheath. In one or more embodiments described herein, the system can include at least three electrodes, including two cathode electrodes and one anode electrode. For example, one of the leads may have two electrodes, while the other lead may have one electrode. Each electrode can be operably coupled to a distal portion of a conductor extending through a sheath of an implantable lead. The proximal portion of the conductor may be operably coupled to one or more electrical connectors at the proximal portion of the lead.

Various types of electrical connectors may be used to provide an operative connection between an implantable medical device and one or more conductors. In one or more embodiments described herein, one example of an electrical connector has a bifurcated proximal end. Each branch may include or be described as an IS connector. In some embodiments, another example of an electrical connector has two separate IS connectors. In one or more embodiments described herein, another example of an electrical connector has an inner conductor and two outer conductors. The inner conductor may be operably coupled to the second electrode 124, and the two outer conductors may be operably coupled to the first electrode 122 and the return electrode 126. In some embodiments, such an electrical connector may be described as an IS-4 connector.

Fig. 4 depicts a cross-sectional view of one example of the distal portion 112 of the lead introduction system 100 including various conductors operably coupled to electrodes. Any suitable conductor known to one of ordinary skill in the art having the benefit of this disclosure may be used for an implantable lead that extends through the system 100.

The second implantable lead 104 may extend through a lumen 105 formed by the first implantable lead 102. The second implantable lead 104 can further define a lumen 135, and the stylet 130 can extend at least partially through the lumen to facilitate advancement and direction of the distal portion 112 of the control system 100 during the implantation procedure.

The first electrode 122 is integrally formed with the fixation element 108 and coupled to the first implantable lead 102. The first electrode 122 is operably coupled to a first conductor 132 that extends through the first implantable lead 102. The first conductor 132 may be disposed in the lumen 105 of the first implantable lead 102. The electrodes of the conductors may extend through the sealing element 107 to establish an electrical connection between the first electrode 122 and the first conductor 132.

Also, as shown, the second electrode 124 is integrally formed with the fixation element 109 and is coupled to the second implantable lead 104. The second electrode 124 is operably coupled to a second conductor 134 that extends through the second implantable lead 104. The second conductor 134 may be disposed in the lumen 135 of the second implantable lead 104. Another conductor may also extend through the first implantable lead 102. As shown, the return electrode 126 is operably coupled to a third conductor 136 that extends through the lumen 105 of the first implantable lead 102. Any suitable conductor type known to those of ordinary skill in the art having the benefit of this disclosure may be used. In the illustrated embodiment, each of the conductors is a coil conductor, which may facilitate flexibility of the respective lead.

In some embodiments, the distal portion of the second implantable lead 104 can comprise a single chip controlled release device (MCRD). The MCRD may be positioned proximate to the second electrode 124.

Fig. 5 depicts a cross-sectional view of one example of the proximal portion 110 of the lead in system 100 including an electrical connector operatively coupled to a conductor. As shown, electrical connector 140 includes a first IS connector 142 and a second IS connector 144. First conductor 132 and third conductor 136 are operably coupled to first IS connector 142, for example using coil joints. First conductor 132 may be coupled to a proximal contact at a proximal end or tip of first IS connector 142, and third conductor 136 may be coupled to a proximal ring contact distal to the proximal end or tip. The second conductor 134 IS operably coupled to a second IS connector 144 having at least one proximal contact. The proximal contact of the IS connector may be used to operably couple to IMD 16 of fig. 2 or 3.

In the illustrated embodiment, the first and second implantable leads 102, 104 are coupled by a lead fixation element 103. The stylet 130 extends through the lumen 135 of the second implantable lead 104 and through the lead fixation element 103, and may be coupled proximally to the stylet driver.

Fig. 6 depicts one example of the proximal end of a drop lead system with a bifurcated electrical connector 160. The electrical connector 160 has a bifurcated proximal end. Two electrodes, such as the first electrode 122 and the return electrode 126 of fig. 2 or 3, may be operably coupled to a conductor extending through one branch 162 of the bifurcated proximal end, while another electrode, such as the second electrode 124 of fig. 2 or 3, may be operably coupled to a conductor extending through the other branch 164. Each branch may be described as an IS connector. The electrical connector 160 can include a coupling region 166 where the electrical connector 160 can interface with an implantable lead. Electrical connector 160 may have the same or similar proximal contacts as electrical connector 140 for coupling to IMD 16.

Fig. 7 depicts a cross-sectional view of one example of a coupling region 176 of an electrical connector 170 that may be used in a drop wire system. The coupling region 176 can be coupled to the first implantable lead 102 to be operably coupled to the first conductor 132 and the third conductor 136. The second conductor 134 of the second implantable lead 104 can extend through the coupling region 176 and be operably coupled to a proximal contact at a proximal end or tip of the electrical connector 170. The first conductor 132 and the third conductor 136 may each be operably coupled to a proximal ring contact distal to a proximal end or tip.

Various embodiments of the present disclosure provide a method of delivering a lead-in system for cardiac therapy to targeted various regions within a patient's heart. Fig. 8 depicts one example of a method 200 for delivering an lead in system that includes implanting 202 a first electrode of a first implantable lead at an implantation site on or in a tissue structure of a heart of a patient. The method 200 can also include advancing a second implantable lead having a second electrode guided by the distal portion of the first implantable lead to the same implantation site 204. The method 200 may further include implanting 206 a second electrode at the same implant site remote from the first implanted lead electrode.

The first implantable lead and the second implantable lead may be advanced toward the implantation site simultaneously. In some embodiments, implanting the second electrode includes translating the second electrode relative to the first electrode after the first electrode has been implanted to allow the second electrode to be implanted at various selectable depths within tissue structures of the patient's heart. Implanting the second electrode may also include delivering electrical pulses to test one or more depths of the first electrode or the second electrode in tissue structures of the patient's heart.

In some embodiments, implanting the electrode of the first implantable lead may include advancing a guidewire to the implantation site. The guidewire may pierce or puncture the surface of the tissue structure. The first implantable lead may be guided over a guidewire to an implantation site. When the first implantable lead has been properly implanted, the guidewire may optionally be removed. The second implantable lead may be guided by the lumen of the first implantable lead or over a guidewire to the implantation site. The second implantable lead can be advanced (e.g., drilled or screwed) distally into the tissue structure at the implantation site.

Fig. 9, 10, and 11 schematically depict various stages in performing one example of a method 200, in particular, for delivering a lead in system for VfA cardiac therapy, such as lead in system 100 (fig. 2) or lead in system 150 (fig. 3). In fig. 9, the deflectable catheter 300 is advanced to and placed against the koch triangle in the patient's heart. In fig. 10, a bipolar outer lead 302 (e.g., a first implantable lead) of the system is implanted through a catheter 300 and secured at a koch triangle near the coronary sinus ostium. In fig. 11, once the bipolar outer lead 302 of the system is secured at koch's corner near the coronary sinus ostium, the inner lead 304 of the system (e.g., a second implantable lead) is implanted through the outer lead lumen and secured into the atrial septal wall by rotating the inner lead body. Fig. 12 is a flow chart illustrating one example of a particular method 250 for performing the method 200, in particular, for delivering an introduction lead system for VfA cardiac therapy. The method 250 may include placing the catheter against a koch triangle 252 (see fig. 9). The method 250 may also include inserting a bipolar outer lead of the system through the catheter and securing the lead against the koch triangle 254 (see fig. 10). The method 250 may determine whether the bipolar outer lead captures the atrium, particularly the right atrium 256. If the atrium is not captured, the method 250 may return to inserting the bipolar lead into a new location in the Koch triangle 254. If the atrium is captured, the method 250 may include inserting an inner lead of the system into the outer lead lumen and placing the inner lead against the atrioventricular wall 258 (see fig. 11). The method 250 may also include carefully rotating 260 the inner lead into the left side of the patient's heart into the atrioventricular wall while performing the test pacing (see fig. 11).

The method 250 may further determine whether an expected pacing ECG or pacing impedance is observed during the inner lead rotation process 262. If the expected ECG or pacing impedance is observed, the method 250 may determine that implantation is complete 264. For example, the lead may then be coupled to the IMD. Otherwise, the method 250 may continue to rotate the inner lead 260 while testing pacing.

Fig. 13 depicts a system 350 that may utilize a lead-in lead system 352 and a defibrillator lead 354, lead-in lead system 352 being either lead-in lead system 100 (fig. 2) or lead-in lead system 150 (fig. 3), lead-in lead system 352 and defibrillator lead 354 each being coupled to IMD 16 to provide cardiac therapy that may include VfA pacing (e.g., DDDR type pacing) and defibrillation. The defibrillator lead 354 may be implanted, for example, in the RV of a patient's heart.

Fig. 14, 15 and 16 schematically depict various stages of performing one example of a method 200, in particular for delivering an lead-in system, such as lead-in system 100 (fig. 2) or lead-in system 150 (fig. 3), for biventricular conduction branch pacing or in other words bibundle branch cardiac therapy. In fig. 14, deflectable catheter 400 is advanced to and placed against the RV high septum wall below the anterior septal tricuspid commissure (e.g., about 1 to 3 centimeters (cm) below). In fig. 15, a bipolar outer lead 402 of the system (e.g., a first implantable lead) is implanted through a catheter 400 and secured at the right ventricular septum wall below the anterior septal tricuspid commissure (e.g., about 1cm to 3cm below). In fig. 16, once the bipolar outer lead 402 of the system is secured at the right ventricular septal wall, the inner lead 404 of the system (e.g., a second implantable lead) is implanted through the outer lead lumen and secured into the septal wall by rotating the inner lead body to the left high septal wall (e.g., at the bundle branch).

Fig. 17 is a flow chart illustrating an example of a particular method 450 for performing method 200, in particular, for delivering a lead in system for dual-bundle cardiac therapy, such as lead in system 100 (fig. 2) or lead in system 150 (fig. 3). The method 450 may include placing a catheter against the right ventricular septum wall 452 (see fig. 14) below the anterior septal tricuspid commissure (e.g., about 1cm to 3cm below). The method 450 may further include inserting a bipolar outer lead of the system through the catheter and securing the bipolar outer lead at the right ventricular septum wall 454 below the anterior septal tricuspid commissure (e.g., about 1cm to 3cm below) (see fig. 15).

The method 450 may further include inserting an inner lead of the system into the outer lead lumen and placing the inner lead against the right ventricular septum wall 456 (see fig. 16). The method 450 may include carefully rotating the inner lead into the right ventricular septum wall towards the left side of the patient's heart while performing the test pacing 458 (see fig. 16).

The method 450 may include determining whether a left beam purkinje potential or an expected pacing impedance from the EGM using the second electrode is observed 460. If a left beam purkinje potential or pacing impedance is observed, the method 450 may determine that the implantation is complete 462. For example, the lead may then be coupled to the IMD. Otherwise, the method 450 may continue to rotate the inner lead 458 while testing pacing.

Optionally, the method 450 further includes rotating the bipolar outer lead and performing test pacing until a right beam purkinje potential, an expected EGM, or a pacing impedance is observed.

Fig. 18 depicts a system 500 that may utilize a lead system 502 and an atrial lead 504, where lead system 502 may be lead system 100 (fig. 2) or lead system 150 (fig. 3), where both lead system 502 and atrial lead 504 are coupled to IMD 16 to provide cardiac therapy that may include dual bundle branch pacing (e.g., DDDR-type pacing). The atrial lead 504 may be implanted in an RA of the patient's heart.

Fig. 19 depicts a system 510 that may utilize a lead system 502, an atrial lead 504, and a defibrillator lead 506, lead system 502 may be lead system 100 (fig. 2) or lead system 150 (fig. 3), and lead system 502, atrial lead 504, and defibrillator lead 506 are each coupled to IMD 16 to provide cardiac therapy that may include dual-bundle branch pacing (e.g., DDDR-type pacing) and defibrillation. The defibrillator lead 506 may be implanted, for example, in the RV of a patient's heart.

Various lead introduction systems may also be used to access the coronary vasculature (e.g., coronary sinus and coronary vein) for left-side cardiac therapy. Fig. 20 shows one example of a system 520 for left-side cardiac therapy, which system 520 may be similar or identical to lead-in system 100 (fig. 2) or lead-in system 150 (fig. 3). System 520 includes a first implantable lead 522 and a second implantable lead 524. The first electrode 532 may be coupled to a distal portion of the first implantable lead 522 (e.g., an outer lead) and implanted in a coronary vein (e.g., a great cardiac vein). A second implantable lead 524 (e.g., an inner lead) can extend distally from the first implantable lead 522. Second electrode 534 may be coupled to a distal portion of second implantable lead 524. The second electrode 534 is positioned away from the first electrode 532 (e.g., further along the great cardiac vein). The first electrode 532 may capture the LA of the patient's heart and the second electrode 534 may capture the LV of the patient's heart.

System 520 may be implanted using any suitable technique. One example of an implantation method may include implanting the first implantable lead 522 to implant the first electrode 532 at a first implantation site in a coronary sinus or a coronary vein of a heart of a patient. The method may further comprise advancing a second implantable lead 524 having a second electrode 534, guided by the distal portion of the first implantable lead 522, to a second implantation site in a coronary vein of the patient's heart distal to the first electrode 532. The method may further include implanting a second electrode 534 at the second implantation site.

Fig. 21 shows one example of a system 540 for left-side cardiac therapy, which system 540 may be similar or identical to lead-in system 100 (fig. 2) or lead-in system 150 (fig. 3). System 540 includes a first implantable lead 542 and a second implantable lead 544. The first electrode 552 can be coupled proximal to a distal portion 546 of a first implantable lead 542 (e.g., an outer lead) and implanted in the coronary sinus. A second implantable lead 544 (e.g., an inner lead) can extend distally from the first implantable lead 542 and through a puncture 548, such as a micro-puncture, in a coronary vessel wall (e.g., a wall of a central vein). A second electrode 554 may be coupled to a distal portion of the second implantable lead 544 and may extend into the pericardial space of the patient's heart and be epicardially implanted into the myocardium, such as the LV myocardium. The first electrode 552 may capture the LA of the patient's heart and the second electrode 554 may capture the LV of the patient's heart.

In particular, the second implantable lead 544 can extend from a blood vessel through the puncture 548 into the pericardial space extending between the epicardium and the pericardium of the patient's heart. The distal end of the second implantable lead 544 can be located at different locations within the pericardial space to access different implantation sites in the myocardium (e.g., LV myocardium) through the epicardium outside of the coronary vasculature.

Guidewire 556 can be used to form a puncture in the vessel wall and then be retracted from system 540. A structure of the first implantable lead 542, such as the distal portion 546, can be advanced into the puncture 548 and positioned adjacent the puncture to seal the puncture.

The system 540 may be implanted using any suitable technique. One example of an implantation method may include advancing second electrode 554 of second implantable lead 544, guided by distal portion 546 of first implantable lead 542, to a location in the coronary sinus or coronary vein of the patient's heart. The method may further include implanting the first electrode 552 at a first implantation site in a coronary sinus or a coronary vein of a heart of a patient. The method can further include penetrating a pericardial space of a patient's heart through a vessel wall at a location in the coronary sinus or coronary vein, for example, using a guidewire 556. The method may further include advancing the second implantable lead 544 through a puncture 548 in the vessel wall into the pericardial space. In addition, the method may include implanting a second electrode 554 from the pericardial space into the epicardium and myocardium of the patient's heart at a second implantation site remote from the first implantation site. The second implantation site may be in a myocardium outside a coronary sinus or coronary vein of a heart of the patient. In some embodiments, implanting the first electrode 552 after implanting the second electrode 554 may facilitate sealing the puncture 548 by the first implantable lead 542.

Fig. 22 illustrates one example of a system 560 for left-side cardiac therapy, the system 560 may be similar or identical to the lead in system 100 (fig. 2) or the lead in system 150 (fig. 3). System 560 includes a first implantable lead 562 and a second implantable lead 564. The first electrode 572 can be coupled to a distal portion of a first implantable lead 562 (e.g., an outer lead) and implanted in a central vein (e.g., a coronary vein). A second implantable lead 564 (e.g., an inner lead) may extend distally from the first implantable lead 562. The second electrode 574 can be coupled to a distal portion of the second implantable lead 564 and can extend into a myocardium of a patient's heart, such as the LV myocardium. The first electrode 572 may capture the LA of the patient's heart and the second electrode 574 may capture the LV of the patient's heart.

Fig. 23 illustrates an example of an IMD 16, the IMD 16 including: a connector receptacle 40, the connector receptacle 40 configured to receive a lead or a lead connector from a drop lead system, such as the drop lead system 100 (FIG. 2) or the drop lead system 150 (FIG. 3); a therapy delivery circuit 42 operatively coupled to the connector receptacle; a sensing circuit 44 operatively coupled to the connector receptacle; and a controller 46 operably coupled to the therapy delivery circuitry and the sensing circuitry.

Therapy delivery circuitry 42 is configured to deliver cardiac therapy to the patient's heart through one or more operatively connected electrodes (e.g., electrically connected via connector receptacle 40). Sensing circuitry 44 is configured to sense electrical activity of the patient's heart using, for example, one or more operatively connected electrodes (electrically connected via connector receptacle 40). The electrodes operatively coupled to the sensing circuitry 44 may or may not include some or all of the electrodes also operatively coupled to the therapy delivery circuitry 42. The sensing circuitry 44 may monitor electrical activity of the patient's heart, for example, using electrical signals such as Electrocardiogram (ECG) signals or Electrogram (EGM) signals.

The controller 56 may have processing circuitry operatively coupled to the therapy delivery circuitry 42 and the sensing circuitry 44. Controller 46 may be used to perform various functions of IMD 16, which IMD 16 is coupled to a lead in system described herein, such as lead in system 100 (fig. 2) or lead in system 150 (fig. 3).

The processing circuitry may include any one or more of a microprocessor, controller, Digital Signal Processor (DSP), Application Specific Integrated Circuit (ASIC), Field Programmable Gate Array (FPGA), or equivalent discrete or integrated logic circuitry. In some examples, the processing circuitry may include multiple components (e.g., any combination of one or more microprocessors, one or more controllers, one or more DSPs, one or more ASICs, or one or more FPGAs), as well as other discrete or integrated logic circuitry. The functionality attributed to the processing circuitry of the controller herein may be implemented as software, firmware, hardware, or any combination thereof. The controller may control the therapy delivery circuitry to deliver stimulation therapy to the patient's heart in accordance with a selected one or more of the therapy programs that may be stored in the memory. In particular, the controller may control the therapy delivery circuitry to deliver electrical pulses having an amplitude, pulse width, frequency, or electrode polarity specified by the selected one or more therapy programs.

The controller 46 may include a memory. Non-limiting examples of memory may include any volatile, non-volatile, magnetic, optical, or electrical media, such as Random Access Memory (RAM), read-only memory (ROM), non-volatile RAM (NVRAM), Electrically Erasable Programmable ROM (EEPROM), FLASH memory, or any other digital media.

Illustrative aspects of lead-in systems and methods

While the present disclosure is not so limited, an understanding of various aspects of the present disclosure will be gained through a discussion of the specific illustrative lead in systems or methods thereof provided below. Various modifications of the examples and illustrative aspects, as well as additional aspects or features of the disclosure, will be apparent herein.

In the illustrative aspect a1, a method includes implanting a first implantable lead to implant a first electrode of the first implantable lead at a first implantation site in a coronary sinus or a coronary vein of a heart of a patient. The method also includes advancing a second implantable lead having a second electrode guided by the distal portion of the first implantable lead to a second implantation site in a coronary vein of the patient's heart distal to the first electrode. The method further includes implanting a second electrode at a second implantation site.

In illustrative aspect a2, a method includes the method according to any of aspects a, wherein the first electrode is implanted in a coronary sinus or a coronary vein of the patient's heart and the second electrode is implanted in a coronary vein of the patient's heart distal to the first electrode.

In illustrative aspect a3, a method includes a method according to any aspect a, the method further comprising: delivering cardiac therapy to the Left Atrium (LA) or sensing electrical activity of the left atrium; and delivering cardiac therapy to the Left Ventricle (LV) or sensing electrical activity of the left ventricle.

In illustrative aspect B1, a method includes advancing a second implantable lead having a second electrode, guided by a distal portion of a first implantable lead having a first electrode, to a location in a coronary sinus or a coronary vein of a heart of a patient. The method further includes implanting a first electrode at a first implantation site in a coronary sinus or a coronary vein of a heart of the patient, and penetrating a pericardial space of the heart of the patient through a vessel wall at a location in the coronary sinus or the coronary vein. The method further includes advancing a second implantable lead into the pericardial space through the puncture in the vessel wall, and implanting a second electrode from the pericardial space into the myocardium of the patient's heart at a second implantation site remote from the first implantation site.

In illustrative aspect B2, a method includes the method according to any of aspects B, wherein the first electrode is implanted in a coronary sinus or coronary vein of the patient's heart and the second electrode is implanted in a myocardium external to the coronary sinus or coronary vein of the patient's heart distal from the first electrode.

In illustrative aspect B3, a method includes a method according to any of aspects B, the method further comprising: delivering cardiac therapy to the Left Atrium (LA) or sensing electrical activity of the left atrium; and delivering cardiac therapy to the Left Ventricle (LV) or sensing electrical activity of the left ventricle.

In illustrative aspect B4, a method comprises the method according to any of aspects B, further comprising advancing the distal portion of the first implantable lead to the location to seal a puncture hole penetrating through a vessel wall.

In illustrative aspect B5, a method includes the method according to any of aspects B, wherein the first electrode is implanted after the second electrode is implanted.

In illustrative aspect C1, a method includes implanting a first implantable lead to implant a first electrode of the first implantable lead at a first implantation site in a coronary sinus or a coronary vein of a heart of a patient. The method also includes advancing a second implantable lead having a second electrode guided by the distal portion of the first implantable lead to a second implantation site in a Left Ventricular (LV) myocardium of the patient's heart distal to the first electrode. The method further includes implanting a second electrode at a second implantation site.

In illustrative aspect C2, a method includes the method according to any of aspects C, wherein the first electrode is implanted in a coronary sinus or a coronary vein of the patient's heart and the second electrode is implanted in a LV myocardial wall of the patient's heart distal from the first electrode.

In illustrative aspect C3, a method includes a method according to any aspect C, the method further comprising: delivering cardiac therapy to the Left Atrium (LA) or sensing electrical activity of the left atrium; and delivering cardiac therapy to the Left Ventricle (LV) or sensing electrical activity of the left ventricle.

In illustrative aspect D1, a system includes a first implantable lead having a distal portion and a first electrode coupled to the distal portion of the first implantable lead. The first electrode is configured to be implanted at a first implantation site in a coronary sinus or a coronary vein of a heart of a patient. The system also includes a second implantable lead having a distal portion and a second electrode coupled to the distal portion of the second implantable lead. The second electrode is configured to be implanted at a second implantation site in the patient's heart distal from the first electrode. The distal portion of the second implantable lead is guided to the first implantation site by the distal portion of the first implantable lead.

In illustrative aspect D2, a system includes the system according to any of aspects D, wherein the first electrode is implantable to deliver cardiac therapy or sense electrical activity of the Left Atrium (LA) to the left ventricle and the second electrode is implantable to deliver cardiac therapy or sense electrical activity of the left ventricle to the Left Ventricle (LV).

In an illustrative aspect D3, a system includes the system according to any of aspects D, wherein the first electrode and the second electrode are both configured to provide pacing pulses.

In an illustrative aspect D4, a system includes the system according to aspects D1 or D2, wherein the first electrode is configured to sense only electrical activity and the second electrode is configured to provide pacing pulses.

In illustrative aspect D5, a system includes the system according to any of aspects D, wherein the second implantable lead includes a plurality of second electrodes configured to deliver cardiac therapy to the Left Ventricle (LV) or sense electrical activity of the left ventricle.

In an illustrative aspect D6, a system includes the system of any aspect D, wherein after the first electrode or the second electrode is implanted, the other of the first electrode or the second electrode is translatable relative to the implanted first electrode or second electrode.

In an illustrative aspect D7, a system includes the system according to any of aspects D, wherein the first electrode or the second electrode is configured to deliver an electrical pulse to test the first implant site or the second implant site.

In illustrative aspect D8, a system includes the system according to any of aspects D, wherein the second implantable lead is freely rotatable relative to the first implantable lead to facilitate implantation.

In an illustrative aspect D9, a system includes the system according to any of aspects D, wherein the first electrode can be implanted before or after the second electrode is implanted.

In illustrative aspect D10, a system includes the system of any of aspects D, wherein the second implantable lead is at least partially receivable in the lumen of the first implantable lead while advancing the second implantable lead to the second implantation site.

In illustrative aspect D11, a system includes the system according to any of aspects D, wherein a sealing element is coupled between the first implantable lead or the second implantable lead to seal a distal end of the first implantable lead against fluid ingress.

In illustrative aspect D12, a system includes the system according to any of aspects D, wherein the first implantable lead includes a first fixation element formed integrally or separately from the first electrode.

In illustrative aspect D13, a system includes the system according to any of aspects D, wherein the second implantable lead includes a second fixation element formed integrally or separately with the second electrode.

In an illustrative aspect D14, a system includes the system according to any of aspects D, wherein the first implantation site is in a great cardiac vein of a heart of the patient.

In an illustrative aspect D15, a system includes the system according to any aspect D, wherein the second implantation site is in a coronary vein of the patient's heart.

In an illustrative aspect D16, a system includes the system according to any of aspects D1-D14, wherein the second implant site is in a Left Ventricle (LV) myocardium of a patient's heart.

In an illustrative aspect D17, a system includes the system of any of aspects D1-D14, wherein the second implantation site is in a myocardium of a patient's heart other than the coronary sinus and coronary veins.

In an illustrative aspect D18, a system includes the system according to aspects D16 or D17, further comprising a puncturing element configured to puncture through a blood vessel wall into a pericardial cavity of a patient's heart at a location along the coronary sinus or coronary vein.

In an illustrative aspect D19, a system includes the system according to aspect D18, wherein the piercing element is a microneedle configured to create a micro-puncture in a vessel wall.

In an illustrative aspect D20, a system includes the system according to aspects D18 or D19, wherein the penetrating element extends distally from a guidewire receivable within a lumen of the first implantable lead.

In an illustrative aspect D21, a system includes the system according to any aspect D18-D20, wherein the structure of the first implantable lead is configured to seal the puncture when the first electrode is implanted.

In illustrative aspect D22, a system includes the system according to any of aspects D, wherein the first electrode is proximate a distal end of the first implantable lead.

Accordingly, various aspects of lead-in lead systems and methods for cardiac therapy are disclosed. Although reference is made herein to a collection of drawings that form a part of this disclosure, at least one of ordinary skill in the art will appreciate that various adaptations and modifications of the aspects or features described herein are within the scope of the disclosure or do not depart therefrom. For example, aspects of the disclosure described in this disclosure may be combined with one another in various ways. It is, therefore, to be understood that within the scope of the appended claims, the claimed invention may be practiced otherwise than as specifically described herein.

It should be understood that the various aspects disclosed herein may be combined in different combinations than those specifically set forth in the description and drawings. It will also be understood that certain acts or events of any process or method described herein can be performed in a different order, may be added, merged, or omitted entirely, according to examples (e.g., all described acts or events may not be necessary to perform the techniques). Additionally, while certain aspects of the disclosure are described as being performed by a single module or unit for clarity, it should be understood that the techniques of the disclosure may be performed by a combination of units or modules associated with, for example, a medical device. In one or more examples, the techniques described may be implemented in hardware, software, firmware, or any combination thereof. If implemented in software, the functions may be stored on a computer-readable medium as one or more instructions or code and executed by a hardware-based processing unit. The computer-readable medium may include a non-transitory computer-readable medium corresponding to a tangible medium such as a data storage medium (e.g., RAM, ROM, EEPROM, flash memory, or any other medium that can be used to store desired program code in the form of instructions or data structures and that can be accessed by a computer). The instructions may be executed by one or more processors, such as one or more Digital Signal Processors (DSPs), general purpose microprocessors, an Application Specific Integrated Circuits (ASICs), field programmable logic arrays (FPGAs), or other equivalent integrated or discrete logic circuitry. Thus, the term "processor" as used herein may refer to any of the foregoing structure or any other physical structure suitable for implementing the described techniques. In addition, these techniques may be fully implemented in one or more circuits or logic elements. All references and publications cited herein are incorporated by reference in their entirety for all purposes, except to the extent any is directly contradictory to the present disclosure.

Unless defined otherwise, all scientific and technical terms used herein have the same meaning as commonly understood in the art. The definitions provided herein are to facilitate understanding of certain terms used frequently herein and are not meant to limit the scope of the present disclosure.

Unless otherwise indicated, all numbers expressing feature sizes, quantities, and physical characteristics used in the specification and claims are to be understood as being modified by the term "exactly" or "about". Accordingly, unless indicated to the contrary, the numerical parameters set forth in the foregoing specification and attached claims are approximations that can vary depending upon the desired properties sought to be obtained by those skilled in the art utilizing the teachings disclosed herein or, for example, within the typical ranges of experimental error.

The recitation of numerical ranges by endpoints includes all numbers subsumed within that range (e.g. 1 to 5 includes 1, 1.5, 2, 2.75, 3, 3.80, 4, and 5) and any range within that range. Herein, the term "up to" or "not more than" a numerical value (e.g., up to 50) includes the numerical value (e.g., 50), and the term "not less than" a numerical value (e.g., not less than 5) includes the numerical value (e.g., 5).

The terms "coupled" or "connected" mean that the elements are attached to each other either directly (in direct contact with each other) or indirectly (with one or more elements between and attaching two elements). Both terms may be modified by "operational" and "operable," which may be used interchangeably to describe a linkage or connection configured to allow components to interact to perform at least some functions.

The term "configured to" refers to an element having an appropriate structure to perform a particular function. Suitable configurations may be selected by those having the benefit of this disclosure and at least one of ordinary skill in the art. As used herein, the term "configured to" is used interchangeably with the terms "adapted to" or "configured to" unless the disclosure clearly indicates otherwise.

Orientation-related terms, such as "proximal," "distal," "above," or "below," are used to describe relative positions of components and are not meant to limit the orientation of the contemplated embodiments.

Reference to "one embodiment," "an embodiment," "certain embodiments," or "some embodiments," etc., means that a particular feature, configuration, composition, or characteristic described in connection with the lead in is included in at least one aspect of the present disclosure. Thus, the appearances of such phrases in various places throughout this specification are not necessarily referring to the same lead-in of the present disclosure. Further, the particular features, configurations, compositions, or characteristics may be combined in any suitable manner in one or more lead-in wires.

As used in this specification and the appended claims, the singular forms "a", "an" and "the" encompass embodiments having plural referents, unless the content clearly dictates otherwise. As used herein, "having," including, "and the like are used in their open sense and generally mean" including, but not limited to. It will be understood that "consisting essentially of …", "consisting of …", and the like are included in the "comprising" and the like.

The term "and/or" means one or all of the listed elements or a combination of at least two of the listed elements.

The phrases "at least one of," "including at least one of … …," and "one or more of" following a list refer to any one of the items in the list as well as any combination of two or more of the items in the list.

Claims

1. A system, comprising:

a first implantable lead comprising a distal portion and a first electrode coupled to the distal portion of the first implantable lead, wherein the first electrode is configured to be implanted at a first implantation site in a coronary sinus or a coronary vein of a heart of a patient; and

a second implantable lead comprising a distal portion and a second electrode coupled to the distal portion of the second implantable lead, wherein the second electrode is configured to be implanted at a second implant site in the patient's heart distal to the first electrode, wherein the distal portion of the second implantable lead is guided to the first implant site by the distal portion of the first implantable lead.

2. The system of claim 12, wherein the first electrode is implantable to deliver cardiac therapy to a Left Atrium (LA) or sense electrical activity of the left atrium, and the second electrode is implantable to deliver cardiac therapy to a Left Ventricle (LV) or sense electrical activity of the left ventricle.

3. The system of claim 12, wherein the first electrode and the second electrode are both configured to provide pacing pulses.

4. The system of claim 12, wherein the first electrode is configured to sense only electrical activity and the second electrode is configured to provide pacing pulses.

5. The system of claim 12, wherein the second implantable lead includes a plurality of second electrodes configured to deliver cardiac therapy to the Left Ventricle (LV) or sense electrical activity of the left ventricle.

6. The system of claim 12, wherein after the first or second electrode is implanted, the other of the first or second electrode is translatable relative to the implanted first or second electrode.

7. The system of claim 12, wherein the first electrode or the second electrode is configured to deliver an electrical pulse to test the first implant site or the second implant site.

8. The system of claim 12, wherein the second implantable lead is freely rotatable relative to the first implantable lead to facilitate implantation.

9. The system of claim 12, wherein the first electrode is implantable before or after the second electrode is implanted.

10. The system of claim 12, wherein the second implantable lead is at least partially receivable into a lumen of the first implantable lead while advancing the second implantable lead to the second implantation site.

11. The system of claim 12, wherein a sealing element is coupled between the first implantable lead or the second implantable lead to seal a distal end of the first implantable lead from fluid ingress.

12. The system of claim 12, wherein the first implantable lead includes a first fixation element formed integrally or separately from the first electrode.

13. The system of claim 12, wherein the second implantable lead includes a second fixation element formed integrally or separately from the second electrode.

14. The system of claim 12, wherein the first implant site is in a great cardiac vein of the patient's heart.

15. The system of claim 12, wherein the second implantation site is in a coronary vein of the patient's heart.

16. The system according to claim 12, wherein the second implant site is in a Left Ventricle (LV) myocardium of the patient's heart.

17. The system of claim 12, wherein the second implant site is in the myocardium of the patient's heart outside of the coronary sinus and the coronary veins.

18. The system of claim 27 or 28, further comprising a puncturing element configured to puncture through a blood vessel wall into a pericardial cavity of the patient's heart at a location along the coronary sinus or the coronary vein.

19. The system according to claim 29, wherein said piercing element is a microneedle configured to create a micro-puncture in the vessel wall.

20. The system of claim 29, wherein the penetrating element extends distally from a guidewire configured to be received within a lumen of the first implantable lead.

21. The system of claim 29, wherein the first implantable lead is structured to seal the puncture when the first electrode is implanted.

22. The system of claim 12, wherein the first electrode is proximate a distal end of the first implantable lead.